- Prepares, updates, and maintains a medical record for each patient ensuring accuracy of information.
- Maintains appointment system for patients and clinical staff where applicable.
- Tracks compliance with internally scheduled patient appointments, making timely reminder notices to staff prior to each appointment where applicable. Files/scans laboratory, radiology, and other reports in appropriate sections of the electronic medical record within prescribed timeline.
- Routes clinical reports to appropriate clinic staff within prescribed timeline.
- Archives clinical information from the medical record within prescribed timeline in accordance with established policy and procedures.
- Reviews all documentation for completeness and routes incomplete documents to the appropriate provider for correction prior to placing/scanning in the medical records.
- Uses multiple systems to process a variety of narrative and tabular material (e.g., correspondence, tabular data, reports, etc.) to prepare, update, and maintain a medical record and provide required and requested information to appropriate medical personnel.
- Performs record keeping functions in accordance with program policies and position.
- Maintains a high level of proficiency and ease of use utilizing electronic health records.
- Completes and passes Medical Records Technician competencies initially and annually.
- Completes all initial, annual and ad hoc training as required/assigned.
- Serves as a team member for analyzing established protocol practices and identifying areas for improvement.
- Maintains patient confidentiality, and confidentiality of medical records in compliance with the Privacy Act and HIPAA regulations in all work activities.
- Adheres to and maintains awareness of; Policies, Procedures, Directives, Operational Memoranda and accreditation standards as prescribed by customer.
- Adheres to and participates in: Safety, Prevention, Infection and Control, Quality Improvement, Patient Education and other programs and collateral duties as appropriate to position.
- Attends and participates in general/medical staff meetings.
- High School Diploma or GED equivalent.
- Minimum of one-year experience in a healthcare setting as a medical record technician, medical record clerk, unit secretary, or similar position where the processing of electronic medical/health records was part of the daily responsibilities.
- Ability to obtain/maintain required security clearance.
- Ability to obtain/maintain pre-employment medical clearance.
- Knowledge of the basic principles of standard electronic medical record procedures, methods, and requirements to perform a full range of routine medical records management.
- Knowledge of the procedures, rules, operations, sequence of steps, documentation requirements, time requirements, functions, and workflow to process electronic medical records, to review records for accuracy and completeness, and to keep track of processing deadlines.
- Knowledge of medical terminology.
- Ability to manage high volume of medical records daily to include intake, discharge, and requests for records from outside sources.
- Receives and processes requests for information in accordance with the Fair Information Practice Principles and Privacy Act.
- Ability to recognize documentation inconsistencies and take appropriate action to resolve.
- Ability to maintain an electronic medical record system and ensure compliance with all regulatory agencies that provide governance and guidance on handling medical records in an appropriate manner.
- Ability to work in a multi-cultural and multi-lingual environment.
- Ability to work approximately 90% of time using computers, scanners, and printers.
- Ability to utilize telephonic interpreter/translation services to complete assigned duties if not fluent in a language the patient understands.
- Ability to adapt to sudden changes in schedules and flexibility in work requirements.
- Ability to communicate proficiently in English (verbal and written) in order to develop positive rapport with patients, co-workers and other stakeholders.
- Ability to establish and maintain positive working relationships in a multidisciplinary environment.
- Ability to navigate in an electronic work environment including electronic health records, web-based trainings, and communications.
- Knowledge of regulations (HIPAA/Privacy Act) regarding the confidentiality of patient medical records and information as well as Personally Identifiable Information (PII).
- Strong communication skills in both verbal and written.
- Excellent interpersonal skills.
- Proficient in Microsoft Office (MS word, Excel, PowerPoint Outlook and SharePoint).
- Verbal and written proficiency in Spanish is preferred.
- Prior experience in a detention/correctional or residential healthcare setting is preferred, not required.
- Facility Operates 24/7/365; an employee may be required to respond during an emergency activation.
- Ability to work non-traditional hours including evenings, as well as weekends and holidays. Night shifts may be requested at times based on mission needs but are generally not required. (Site specific).
- The work requires some physical exertion, such as long periods of standing; walking or jogging unaided over rough, uneven, or rocky surfaces; recurring bending, crouching, stooping, stretching, reaching, or similar activities; or recurring lifting of moderately heavy patients or equipment.
- The work may require specific, but common, physical characteristics and abilities, such as agility and dexterity, visual, and hearing capabilities.
- Must be able to respond to any medical emergency in the facility, via foot, within four minutes and perform CPR/emergency care standing or kneeling.
- Ability to work efficiently under deadlines and pressure.
- Ability to keep up in a fast-paced environment.
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Medical Records Technician - Dilley, United States - SOS International LLC
Description
Overview
_ This position is contingent upon contract award
_
SOSi is seeking a Medical Records Technician (MRT) responsible for the day to day tasks required to maintain the electronic health record(eHR) for a government customer to work onsite in Dilley, TX.
The responsibilities include, but are not limited to: receiving, scanning, verifying, and filing medical documentation ensuring complete medical records are provided when required.
The role of the MRT is integral to the overall function of the clinic and patient care, ensuring accuracy and timeliness of available information for providers while also monitoring ongoing tasks for completeness.
Through the eHR system, the MRT will schedule appointments as requested, perform data entry and running of data reports from the system.
The MRT must always maintain confidentiality and security of the eHR.Essential Job Duties
Minimum Requirements
REQURED LICENSURE/CERTIFICATION
Maintains Heartsaver CPR AED certification through the American Heart Association.
Preferred Qualifications
Work Environment
All interested individuals will receive consideration and will not be discriminated against on the basis of race, color, religion, sex, national origin, disability, age, sexual orientation, gender identity, genetic information, or protected veteran status.
SOSi takes affirmative action in support of its policy to advance diversity and inclusion of individuals who are minorities, women, protected veterans, and individuals with disabilities.